Republica Bolivariana de Venezuela
Republica Bolivariana de VenezuelaMinisterio del Poder Popular para la Educacin Superior
Universidad del Zulia
Facultad de Medicina
Escuela de Medicina
Catedra de Semiologia-Patologia Medica
HUM-HCHistoria Clnica Integral
Fecha:___/___/___A. Datos de Identificacin:
Nombres y Apellidos:____________________________________________________
Edad:___________ Sexo:________________Grupo tnico:_____________________ Religin:___________________ Raza:______________Grupo Sanguneo:________ Estado Civil:______________ Lugar y Fecha de nacimiento:___________________ ______________________________________________________________________
Nacionalidad:___________________ Profesin u Ocupacin___________________Direccin Actual:_______________________________________________________ ______________________________________________________________________Grado de Instruccin:_______________ Fecha de Ingreso:_____________________Numero de Habitacin:____________ Telfonos:_____________________________
Informacin Suministrada por:__________________ Parentesco:_______________ Confiabilidad:_________________ B. Motivo de Consulta:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.C. Enfermedad Actual:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.D. Antecedentes
D.1 Antecedentes Personales y Patolgicos:
Hbitos:
a.Dieteticos/Alimenticios:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
b.Alcoholicos:_____________________________________________________________________________________________________________________________________________________________________________________________.
c.Cafeicos:________________________________________________________________________________________________________________________________________________________________________________________________.
d.Tabaquismo:____________________________________________________________________________________________________________________________________________________________________________________________.
e.Drogas:_________________________________________________________________________________________________________________________________________________________________________________________________. f.Sexuales:_____________________________________________________________________________________________________________________________. g.Sueo:__________________________________________________________________________________________________________________________________________________________________________________________________.h.Ejercicios/recreacion:_____________________________________________________________________________________________________________________________________________________________________________________.
i.Condiciones Higinicas:
_________________________________________________________________________________________________________________________________________________________________________________________________________.
Enfermedades y Medicamentos: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.Alergias:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
Hospitalizaciones y Operaciones:
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
Accidentes:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
Transfusiones y Transplantes:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.Trabajos:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
Vivienda:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
Vacunas:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
D.2 Antecedentes Familiares:
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
E. Revisin de Sistemas:
a. Enfermedades Infecto-contagiosas y ETS: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
b.Psiquico:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.c.Cabeza:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
d.Ojos:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
e.Oidos:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.f. Nariz y Senos paranasales: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.g. Boca y Garganta: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.h.Cuello:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.i. Aparato Respiratorio:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.j. Aparato Cardiovascular:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.k. Aparato Digestivo:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.l. Aparato Genitourinario:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.m. Antecedentes Ginecolgicos y Obsttricos:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.n. Neuromuscular, Articulaciones y Huesos:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
. Piel y Anexos:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
o. Endocrino, nutricional y hematopoytico:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.F. Examen Fsico
Signos Vitales:
-Presin Arterial:____________________________________________________.
-Pulso:_____________________________________________________________.
-Respiracion:_________________________________________________________________________________________________________________________________________________________________________________________________________.
-Temperatura:___________________________________________________________________.
-Peso y Talla:___________________________________________________________________.
Condicin General del paciente: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
Cabeza:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
Cuello:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
Torax:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
Abdomen:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.Miembros:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.Neurologico:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
G. Hallazgos Positivos:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.H. Diagnsticos:Diagnstico Sindromatico:____________________________________________.
Diagnstico Anatmico:______________________________________________.
Diagnstico Funcional: _______________________________________________.
Diagnstico Etiolgico: _______________________________________________.
Diagnstico Principal:________________________________________________. Diagnsticos Diferenciales:______________________________________________________________________________________________________________________________________.I. Evolucin Intrahospitalaria: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
Realizado por:
Br:____________________________C.I:_________________Firma:_____________
Br:____________________________C.I:_________________Firma:_____________
Br:____________________________C.I:_________________Firma:_____________
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